1. Eastman, Peggy

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They are known as the "5/50"-the 5 percent of the adult population who account for about 50 percent of annual U.S. health care expenditures. Speakers explored how to improve care for this high-cost, high-need segment of Americans at a briefing on Capitol Hill in Washington, D.C., sponsored by the Alliance for Health Reform in partnership with the Commonwealth Fund.

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High-cost, high-need patients typically are older, are poor, and have multiple health conditions. They are more likely to have cancer or be cancer survivors, and to have cardiovascular disease, diabetes, osteoarthritis, pulmonary disease, dementia, and other illnesses. A recent Perspective article in The New England Journal of Medicine calls improved care of high-need, high-cost patients "an urgent priority," especially with the aging of the U.S. population (N Engl J Med 2016;375:909-911).


At the Capitol Hill briefing, speakers suggested strategies and described innovative care models designed to improve care for this challenging population while saving the U.S. health system money. Promising interventions discussed ranged from a new home and community care benefit for Medicare beneficiaries to physician house calls for the homebound. However, there are barriers to providing needed services to these patients.


Addressing Vulnerable Patients

High-cost, high-need patients are most often adults over age 65 with three or more chronic diseases and a functional limitation, factors which affect their ability to care for themselves or to perform routine daily tasks, said Melinda Abrams, MS, Vice President of the Commonwealth Fund. They have low incomes, have public insurance, and use hospital emergency departments three times as often and are hospitalized five times as often as older adults who are not high in need and high in cost. An estimated one in 20 U.S. adults, or 12 million people, fall into this very sick and needy category.


Despite their higher use of the health system, "this population still has unmet needs," said Abrams. And, she noted, data from the 2009-2011 Medical Expenditure Panel Survey have shown that "high-need adults spent more on health care but were less likely to report that the health system works for them." Abrams said it is important to specifically target this population:


* assess their needs;


* develop effective care plans;


* engage patients and family members in managing their care;


* connect patients to follow-up and support services;


* coordinate care with all providers;


* and monitor patients' progress.



But, while promising programs exist to improve care for costly, high-need older patients, so do barriers, said Abrams. These include a misalignment of financial incentives. As previously reported in Oncology Times (8/25/16 issue), few programs align value-based payment for the most vulnerable patients with value-based physician compensation. Specifically, financial incentives do not always accrue to the physicians who undertake the investment of time and resources to care for high-cost, high-need older patients, said Abrams.


In addition to a misalignment of financial incentives, Abrams also cited these barriers:


* lack of flexibility to cover non-medical services, bearing in mind that unaddressed personal and social needs can adversely affect health, use of health services, and costs;


* lack of interoperable electronic health record systems, which makes coordination among disparate sites and providers difficult;


* professional uncertainty and lack of training to take on new roles (technical assistance is needed for care management and coordination);


* and limited research evidence from multi-site care interventions for high-cost, high-need patients-which makes the case for scaling up these interventions difficult.



Home-Based Oncology Care

To improve care and lower costs for the neediest and sickest older population, it is important to provide care that helps them stay at home, said Karen Davis, PhD, Director of the Roger C. Lipitz Center on Integrated Health Care at the Bloomberg School of Public Health at Johns Hopkins University, Baltimore.


"Medicare beneficiaries with serious physical and/or cognitive impairment need both medical care and long-term services and supports," Davis said. She noted data show that over 14 years the U.S. could save about $112 billion in nursing home costs by delaying nursing home entry by 9 months.


Davis presented a proposed policy solution to improve coverage and care for Medicare beneficiaries with complex needs: Medicare Help at Home, a new home and community benefit for beneficiaries with integrated care needs that would target the two-thirds of the 17 percent of Medicare beneficiaries in the community at risk and not on Medicaid. The proposed new care benefit would provide 20 hours per week of personal care or, alternatively, up to $400 weekly for home and community-based care, along with an individualized care plan and support for family caregivers. Financing of the new Medicare benefit would come from income-related cost sharing, a Medicare beneficiary premium of $42 per month and payroll tax financing of 0.4 percent on employers and employees.


"The current Medicare benefit structure is poorly suited to beneficiaries with serious physical or cognitive impairment who require both medical care and long-term services and supports," said Davis. "About 9 million Medicare beneficiaries with integrated care needs account for 17 percent of all beneficiaries and 32 percent of Medicare spending," she added. She envisions Integrated Care Organizations (ICOs), an extension of Accountable Care Organizations that would implement innovative models of care delivery in the home and community. ICOs would be eligible for shared savings from reduced nursing home placement.


A wake-up call for Peter A. Boling, MD, Professor of Internal Medicine at Virginia Commonwealth University (VCU), occurred when he dealt with high-need, homebound ill patients who were having great difficulty gaining timely access to medical care; were experiencing uncoordinated and discontinuous medical care; had lapses in care plans made at hospitals; had care plans that were not matched with the patients' actual needs; and suffered from insufficient interaction between physicians and home health agencies.


"Ultimately, the patients and their families were desperate for help," said Boling, who is Chair of the VCU Division of Geriatric Medicine and Co-Director of the Virginia Geriatric Education Center. As he thought about the complex needs of these patients, "all of a sudden things got turned upside down." Boling was particularly concerned about poor Medicare patients who had not yet spent down to Medicaid level. "They're really in a precarious situation; it's really embarrassing," he said. Boling concluded that, in many cases, the best way to care for these low-income, high-needs patients is house calls.


Home visits allow the physician "to discover and accurately evaluate the patient's most important problems "and reconcile his/her medicines," said Boling. "The only true 'med rec' [medication reconciliation] is done at the kitchen table." In addition, the physician can understand the needs and capabilities of the patient and caregivers, along with the patient's functional and cognitive status, environmental safety, and social support.


Also, he said, the home visit helps the patient and family develop trust with the physician. Boling emphasized that successful house calls depend on a core team, which includes-in addition to the physician-a nurse practitioner or physician assistant; nurse; social worker; pharmacist consultant; office support staff; IT support for a mobile electronic health record; data manager; and portable diagnostic technology administrator.


Independence at Home Program

Boling's aha moment has been incorporated into Independence at Home (IAH), a voluntary program for Medicare beneficiaries with a house call team led by a physician or nurse practitioner. In March 2010, a law with bipartisan support was passed in Congress establishing an IAH Medicare demonstration project, which was launched in June 2012 at 16 individual sites and three consortia.


Boling, whose site is one of the IAH demonstration participants, said that according to data from the Centers for Medicare & Medicaid Services (CMS), IAH demonstration year one results (June 2015) showed savings of more than $25 million on 8,400 high-cost beneficiaries, for more than $3,000 saved per beneficiary. Some 12 of 17 programs in the demonstration participated in shared savings (saved 5% or more), and CMS awarded incentive payments of $11.7 million. All programs improved on three out of six quality measures and four programs (seven sites) met all six quality measures.


In demonstration year two, nine of 15 active IAH sites report costs that are below target figures, said Boling, with more than $10 million in savings reported by CMS in year two, for a total of about $35 million saved in 2 years. In year two, seven sites were awarded shared savings, and work is ongoing to calibrate the shared savings model, said Boling. On July 31, 2015, the President signed a 2-year extension of the IAH CMS demonstration. A Senate bill, the Independence at Home Act of 2016 (S. 3130), introduced by Sen. Edward Markey (D-Mass.), would implement the IAH model nationally as a permanent medical practice program under Medicare.


Asked by Oncology Times what accounts for most of the IAH savings, Boling said it is the reduction in unnecessary hospitalizations and visits to the emergency department. While not all of the sites participating in the IAH Medicare demonstration project incorporate house calls into their programs to the extent that he has, Boling remains a staunch believer in the value of home visits to the sickest, neediest patients-and he said physicians are becoming more receptive to the idea. Asked how travel time to and from housebound patients can be cost-effective for physicians, he said, "The payment has to be worth their while."


Katherine Hayes, JD, Director of Health Policy for the Bipartisan Policy Center, agreed with Abrams that misaligned financial incentives are often a barrier to the sustainability and spread of successful models of care for high-needs, high-cost older patients. "While changing federal reimbursement policy is not the only solution, without change, financial incentives are a significant barrier to sustainability and spread of successful models," she said.


And she agreed with Davis that high-needs older patients require extensive support services as well as medical services. "For low-income patients, successful care often involves providing health-related interventions designed to address social determinants of health such as housing, nutrition, transportation, and home and community-based services," she said.


Hayes emphasized the need to focus on low-income patients who are dually eligible for Medicare and Medicaid. "I think the most pressing thing now is care of dual eligibles," she said. "It is uncoordinated and complex. We really need to get serious about integrating care for these people."


Peggy Eastman is a contributing writer.


Tips to Care for High-Need Patients


* Assess their needs


* Develop effective care plans


* Engage patients and family members in managing their care


* Connect patients to follow-up and support services


* Coordinate care with all providers


* Monitor patients' progress